Provider Demographics
NPI:1598140071
Name:MCCONNEHEY, KELLI JO (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JO
Last Name:MCCONNEHEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:JO
Other - Last Name:BJORNRUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:355 E ERIE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3167
Mailing Address - Country:US
Mailing Address - Phone:312-238-1000
Mailing Address - Fax:312-238-1417
Practice Address - Street 1:355 E ERIE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3167
Practice Address - Country:US
Practice Address - Phone:312-238-1000
Practice Address - Fax:312-238-1417
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1127468OtherNCCPA CERTIFICATION
ILF400328767OtherMEDICARE PTAN
IL085005524OtherILLINOIS PHYSICIAN ASSISTANT LICENSE